Beyond politics: the Affordable Care Act, your doctor and you
The Supreme Court's decision to mostly uphold the Affordable Care Act (ACA) set off an incessant roar about whom the decision helps or hurts politically. I've wanted to scream, "What about us — the patients? And what about our doctors?"
I'm not alone. The cyber world is flooded with concerns and assumptions, not to mention a whole lot of misinformation. And no wonder.
The debate has been framed in the context of politics and spun to benefit one side or the other, leaving most of us confused and some of us downright scared about how the law will impact that most vital and intimate of relationships: that between patients and doctors. We'll be around long after this election cycle is over.
There are no simple answers to anything as complex as health care, but those who are on the front lines are best qualified to provide accurate insight. Dr. Ora Pescovitz and Rob Casalou are on those front lines, navigating the challenges of providing and improving our care every day.
Dr. Pescovitz is the CEO of the University of Michigan Health System (UMHS), which treated 1.8 million people in an outpatient basis and 45,000 people in the hospital last year.
Mr. Casalou is President and CEO of Saint Joseph Mercy Ann Arbor and Livingston hospitals (SJMHS), which are part of Trinity Health, the 10th largest health care system and the 4th largest Catholic health care system in the country, by total number of hospitals (49 in 10 states) and total bed count, respectively
I'm grateful to Dr. Pescovitz and Mr. Casalou for giving us a view of the law and our health care system from the standpoint of what should matter most — our health care. They point out that:
- doctors, not panels of bureaucrats, will continue to decide what is best for patients
- medical practices and hospitals are building capacity to care for more patients
- there is no evidence that doctors are leaving the practice of medicine
- medical school applicants are up, indicating that there will be more doctors to care
for people in the future
- because our current health care system is not sustainable, doctors and hospitals
began implementing more efficient systems that would reduce cost while improving
patient care and outcomes even before the law was passed
And they tell us so much more, which is why I share their replies to my questions in their entirety.
Q. How - or will - the ACA change our relationships with our doctors?
Mr. Casalou: Our relationship with our doctors continues to change because of the laws of economics and not the laws created by our government. The fact is that our country cannot sustain the costs of the health care system as it is structured today.
The idea of managing populations and trying to reduce costly care is not because of the ACA, it is because of economic reality.
Health care can be expensive, it can be uncomfortable and it can take time away from other priorities in our lives. Yet, it is a product we need and it must be high quality and low cost. Thus, for us to deliver that product, doctors and hospitals must align closely and have common incentives to make sure we try and maintain a healthy population in the communities we serve. This is one of the major reasons we came together with IHA.
Dr. Pescovitz: One of the big things that the ACA emphasizes is quality of care — are doctors and their teams doing everything for patients that we know is proven to work and that can keep people healthy? And, it's tying payment to performance on quality measures and patient satisfaction. This is a big change for our industry and, quite frankly, one that is a long time coming.
Now, hospitals and doctor's offices will be working even harder to make sure patients get the right care at the right time. It will be financially beneficial to avoid unnecessary tests and procedures, reduce duplicative efforts and make process improvements that reduce readmissions, hospital-acquired infections and the like. All of this should help improve patients' overall experience — and health.
For people who haven't had a regular doctor, such as people without insurance, the ACA will make it easier for them to get the kind of regular care they need and build a relationship with a doctor who can work with them on their health issues.
One of the reasons health care spending is so out of control is that, as a nation, we don't do a good job on the preventive side of care and, as a result, people develop preventable chronic conditions that are costly to their health and to the health care system.
With more people having access to care, we have an opportunity to take better care of patients early on and see them regularly as they age and their health needs change. This will have significant long-term impact on the health of our population and on health care spending.
We (UMHS) have a bit of a "head start" on making these kinds of changes because we have spent the last five years proving that we can provide exactly the kind of coordinated, high-quality care that the ACA is designed to encourage, while containing the growth of costs. We did this in a Medicare demonstration project that laid the groundwork for Accountable Care Organizations (ACO), and we're doing it now through our new Pioneer ACO with the physicians of U-M and IHA (a multi-speciality group practice). We are also pioneering a "patient centered medical home" model that the ACA encourages.
Q. Because the ACA gives millions more people access to health care, there is speculation that the influx of new patients will strain the system beyond capacity. What assurance, if any, can you give patients that waiting for months to see doctors won't be the norm?
Mr. Casalou: First, we believe creating the ability for all people to access care is a good thing. We also need to remember that many of the current uninsured patients in our community do access care and use the health care system now. Many pay out of pocket for their health care, and we and other hospitals currently write off all or part of medical bills for the uninsured.
So, while there will be more patients accessing care, not all the newly insured will be incremental to our health care system.
Having said that, we are building capacity, particularly in primary care, to provide a medical home for all our patients. Just this past year our physician partner, IHA, added several primary care doctors and nurse practitioners and will continue to do so in the coming months and years.
We do not anticipate longer wait lists or lower quality in the care of patients as a result of increasing demand.
Q. Our doctors are already constrained by time. Do you anticipate that the time they spend with us will decrease?
Dr. Pescovitz: In my 30 years of treating patients, and working with medical students and residents, there's one constant: We always want to be able to spend more time with our patients, and to be able to see all the patients who want to see us. But, more importantly, we want the time we spend with patients to matter.
I am hopeful that trends in health care, including those influenced by the ACA, will help doctors make the most of the time with patients. With millions more insured Americans, we will definitely see more people seeking access to care they haven't previously had, so we will need to be diligent and responsive to this influx. The ACO model addresses this by suggesting a structure of more coordinated care amongst all members of an individual's health care team.
Also, the ACA incentivizes hospitals and doctor's offices to invest in technologies and care strategies that can make them run more efficiently — such as computer systems and physician extenders. So, these measures may help reduce the time doctors spend on things besides caring for patients. At the same time, there's a great push to increase the supply of doctors.
Q. There is speculation that the ACA is driving doctors who are currently practicing out of medicine and that it will drive the best and the brightest young people to professions other than medicine, which, of course, will mean fewer doctors to treat more people. Are you seeing any evidence of this?
Dr. Pescovitz: I interact with faculty, residents, medical students and community physicians from all over the country all the time, and we all share a common drive to help people get better and live more productive and fulfilling lives. Whether we do that as physicians delivering care, scientists developing treatments or faculty teaching future generations of physician-scientists, it is part of our core. I don't think that has changed or will change. Medicine remains one of the most rewarding and sacred professions.
I don't think the ACA is driving people away from medicine. It would be premature to draw such a conclusion. Actually, more young people are applying to medical school than ever before — 7,000 more nationwide last year compared with a decade ago!
I do think that the profession is changing as lifestyles and priorities change, and as new generations enter the workforce. Today, people prioritize work-life balance differently and are making career decisions that reflect this priority. At the same time, we are seeing young professionals and students with more technological expertise bring new and exciting perspectives and skills that will certainly shape the future of medicine.
Q. We've seen drug shortages as recently as a few months ago. Won't this only get worse as millions of new people enter the system? How is this possibility being addressed?
Mr. Casalou: The other way to look at this question is to say that if we have millions of people who are not receiving adequate care, including medications, isn't it incumbent on us to build the capacity to meet the demand? Wouldn't any other manufacturing or service industry do the same?
While we have dealt with shortages from time to time on various drugs, we have a very large and capable pharmaceutical industry that I am sure is already preparing for additional demand as they deal with current isolated shortages of some medications
Q. The ACA has been called government-run health care. Will the government now dictate what procedures we can or cannot have or will those decisions still rest with our doctors?
Dr. Pescovitz: Those who throw stones at "government run health care" often ignore the fact that huge numbers of Americans already rely on government-run plans such as Medicare, veterans' care, Medicaid, and special programs for sick children.
All of these programs, and insurance plans from private companies, give doctors a lot of leeway to decide what is best for their patients and will continue to do so. As the ACA takes full effect, that should still be true.
But, the other thing that will happen — and this is a very good thing for all of us — is that all forms of health coverage will focus hard on making sure that patients get the care that has been shown to work for people with the same condition as them. This is what is often referred to as "evidence-based medicine."
And there will be more research at places like U-M to actually study what works best, so more patients can get proven care. In fact, our new University of Michigan Institute for Healthcare Policy and Innovation was conceived to bring together hundreds of health services researchers who share a common goal of studying health outcomes to ensure better, safer, more equitable and more cost effective health care.
Q. Serious illnesses such as cancer may require periodic, long term or lifelong treatment. Is there anything in the law that will prevent our doctors from treating us at any time in the course of our illnesses?
Mr. Casalou: I don't see anything in this law that will prevent or withhold appropriate care to patients.
Q. There is speculation that the cost of administering the ACA and/or increased demand will drive up costs which in turn will drive up premiums. True or false and why?
Mr. Casalou: If the only outcome of the ACA is to have more people using the current system with the current cost structure and utilization of high-end services then, yes, costs will go up. However, this outcome would not be economically sustainable.
This is why accountable care was a centerpiece of the legislation. The idea is that we will increase access to care while lowering the cost of care per individual as we maintain health rather than have a system based on sick care. Both of these elements are crucial for this to succeed.
Q. What does the ACA mean to research, clinical trials and patients who want to participate in them?
Dr. Pescovitz: The ACA is already funding a wide range of research that compares medical treatment options and gives us valuable information on what works and what doesn't.
As for clinical trials, the majority of funding for those comes from federal agencies whose budgets aren't affected by the ACA, but are facing budget cuts because of the failure of the "super committee" last year. In fact, federal and state funding for all kinds of medical research, not just clinical trials, is going down — not up — and that's posing a big challenge to research institutions like ours. Groups like Research!America offer a lot of information online about this threat and what members of the public can do about it.
Private companies also fund a lot of clinical trials, and there are new requirements outside of the ACA to make sure that these are done safely and transparently. Additionally, we are seeing a trend in philanthropic support for research, which will become more important as other funding sources dry up.
Q. What would you say to patients who are concerned about the new law?
Dr. Pescovitz: Learn more and get informed! When you strip away the politics, it is clear that most people simply are uninformed and rightfully concerned about what the ACA means for them and their families. Healthcare.gov is a good resource for information, as is healthlawguide.aarp.org.
Also, talk to your doctor and stay engaged in the ongoing conversation as we work through changes in health care. We want patients to be our partners in shaping this change.
Change is never easy, but these changes are long overdue. We must get American health care to a better place. Doctors and hospitals are already becoming more motivated to provide high-quality care and better customer service because of the ACA.
If you have children who are young adults, are in the Medicare prescription drug "doughnut hole," or have a pre-existing condition that makes it hard for you to find affordable insurance, the ACA is already helping you. And no matter what your situation, the ACA is intended to make sure that we as a society spend our health care dollars more wisely, fairly and humanely.
This is a journey. We didn't get here overnight and it will certainly take many years — even decades — to see the full impact of changes we are enacting today. But, positive change is necessary.
Mr. Casalou: I would say to try and filter through the politics and rhetoric of the law. It is complicated and people who are on both sides of the politics of the law spend a lot of time trying to create fear or overstating aspects of the legislation.
The law is far from perfect, but so is our current health care system. Our system needs a transformation and, if the bill has done nothing else, it has put a spotlight on a problem that has been growing for several years, and has become too costly and not accessible to all Americans.
I suspect the law will get refined over time to deal with problems as they arise. For us, we are staying the course.
Q. Most everyone agrees that the current system of American health care is not sustainable. What steps are health care systems like yours taking to decrease costs without sacrificing patient care?
Dr. Pescovitz: For a country that wants to be the best at everything, health care is an area where we lag significantly. We have amazing options for people who have good insurance, and terrible options for people who don't.
As a nonprofit, UMHS provides a large amount of care either for free or at reduced cost to those who don't have coverage. But, we can't do this for everyone. No system can.
As a society, we're spending health care dollars badly, because we pay for emergencies and care for advanced disease that has gone untreated, rather than prevention and lower cost, early-stage intervention.
Make no mistake — if you have insurance, whether through private insurance or a government program, the truth is you already pay for the cost of caring for the uninsured, so it benefits the majority of our country's population to get national health care spending under control. Inaction isn't an option.
The ACA, and changes to health care reimbursement that were taking effect long before the ACA, are making hospitals, doctor's offices and other health providers become more efficient. The ACA and insurers are driving us to make much-needed changes in computerization, quality measurement and customer service that other industries have long had in place. That means reducing waste, to reduce unnecessary costs, but it also means investing in things that will improve the patient experience and provide the care that patients actually need, rather than what pays the bills.
For nearly a decade, we've been working with Blue Cross Blue Shield of Michigan to lead efforts to improve care at hospitals statewide, in specialties such as heart care, cancer care and medical imaging. These are data-driven, cooperative efforts that have resulted in much better outcomes for patients and hundreds of millions of dollars in avoided costs because doctors and hospitals are doing things in consistent, proven ways instead of just the way they've always done them.
Mr. Casalou: For the past four years, we have been getting our health care system ready for the new realities of health care. The plan has many facets including reducing costs through redesign or elimination of costly programs and excess capacity. Examples include the elimination of our helicopter service and contracting with UM, and converting the St. Joseph Mercy Saline hospital into a outpatient health center that more appropriately meets the needs of the community.
In fact, the collaboration between St. Joe's and UM in recent months is intended to benefit our community by eliminating redundancies and coordinating the delivery of services where appropriate.
The plan also includes investments in the front end of care, our physicians, and creating a medical community at St. Joe's that is aligned and cohesive. Examples include the merger with IHA and the subsequent growth of our physician network.
The plan includes redesigning care to create a high quality and safe care environment. We are seeing great results as St. Joe's has received national recognitions and awards this past year for high quality care and patient satisfaction.
And last, but definitely not least, we are working to keep our employees engaged as members of health care family by maintaining a work environment that enriches them as professionals. We keep what is called a "balanced scorecard" where we measure every aspect of our plan to make sure that we are achieving all of our goals and not focused just on one area.